President Obama’s Commitment to an AIDS-Free Generation (and How to Make It Happen)

by Chris Collins

Published Tuesday, February 07, 2012

In ten years, will we look back on President Obama’s 2011 World AIDS
Day speech and see it as a turning point in the AIDS pandemic, or cringe at the
lost opportunity of a singular moment? The
President’s December 1 speech could be pivotal, but only if it is followed by
changes in how we tackle global AIDS.

Why was the Obama speech important?
The President declared that “we can end this pandemic,” calling out the
enormous potential following 18 months of startling scientific progress on
AIDS. He laid out ambitious new
targets for delivery of effective interventions, which, if
accomplished, could substantially reduce rates of HIV infection and
mortality. And in setting those targets,
Obama signaled a renewed U.S. commitment to funding for global AIDS programs at
a time when resources at home are constrained and other countries are backing
away from the fight. The first mission of
America’s global AIDS effort is to alleviate suffering and end AIDS; those
goals should drive resource allocation.

Now it’s time to
plot a course for implementing the President’s vision. We need to act quickly to take advantage of
reinvigorated leadership, aligning resources for tangible impact. Four things are critical to success and deserve
immediate attention: strategic decision making, increased funding, balancing
global targets with attention to the most vulnerable, and research.

First, a new era of efficiency
and strategic resource allocation is needed. An increased share of AIDS resources needs to
reach programs on the ground, and that funding needs to be used for maximum
impact. An AIDS-free generation requires
a shift in resource allocation approaches; ideally, each country would start
each year with a clean-slate budget and determine how to use money most
effectively based on the latest science, epidemiology, and evidence of impact.

We also need to more widely and better use economic modeling to make
evidence-based decisions about recourse allocation. These models are increasingly influential,
and they need to be designed thoughtfully. Choosing the questions and
assumptions that are punched into the computer makes all the difference. It is not enough for models to focus simply
on how we might reduce incidence when the goal of the global AIDS response is
broader: to reduce infections, morbidity, and death.

No one intervention in isolation will move us toward an AIDS-free generation;
it’s going to take a combination of approaches.
That said, using a more strategic lens will lead to changing priorities. For example, in countries where the epidemic
is largely centered on certain populations investments should be focused there. Regardless of epidemic profile, investments
in all countries should be submitted to this test: What public health impact can they be expected
to achieve?

The new AIDS treatment target set by President Obama in his December 1
speech captured most of the media attention, but the President set specific
goals in four areas that day: treatment,
voluntary medical male circumcision, prevention of vertical transmission, and
condom delivery. Those four
interventions will be central to any successful campaign against AIDS. Other interventions will be necessary, too,
including behavior change, syringe exchange, and structural approaches. And it’s long past time to better integrate TB,
sexual and reproductive health, and other services with AIDS programming.

But now that the HPTN 052 study
has conclusively demonstrated that AIDS treatment dramatically reduces the
likelihood HIV will be passed to a partner, scientific leaders are pointing to
treatment delivery as a central ingredient of progress. While more research is needed to understand
the population-level prevention impact of AIDS treatment, there are already signals
worth noting. The UNAIDS annual report from November 2011, for example, cites
four countries where expanded access to HIV treatment appears to be boosting
the effectiveness of combination prevention.
In all of this, we cannot forget an obvious point: Treatment is a public
good beyond its potential for reducing incidence – people thrive, support their
families, raise their children, and contribute to the economy. We won’t solve our
debt problem by slashing global health.

There are critical opportunities in the coming months to drive
strategic efforts as countries supported by the President’s Emergency Plan for
AIDS Relief (PEPFAR) submit their Country Operational Plans (COPs), and grants through
the Global Fund to Fight AIDS, TB and Malaria are reviewed for continuation. The next round of COPs is due in March, and its
success in allocating resources effectively will determine whether the
President’s targets are met. The
discussion about smart use of resources needs more attention, with more civil
society engagement in developing COPs and other programming. The Office of the Global AIDS Coordinator (OGAC)
and its implementing agencies, the Centers for Disease Control and Prevention
(CDC) and USAID, must be clear with countries about the President’s new PEPFAR targets,
and the implications for resource planning.

There is a tension here, as donors, including the U.S., emphasize
increased “country ownership” in decision making around health. There’s no
question donors should be transitioning to more country ownership. But the first mission of America’s global
AIDS effort is to alleviate suffering and end AIDS; those goals should drive resource
allocation.

The second big challenge is finding
new resources. It’s a cruel irony
that the same summer the results of the 052 study were released, a report from
the Kaiser Family Foundation found that, for the first time, global resources
dedicated to fighting AIDS had actually fallen over the last year. In November, the Global Fund cancelled a grant
round for lack of funding. And in
December, the U.S. Congress passed an annual appropriations bill that increased
funding for many areas of global health, yet shaved global AIDS by 2%.

As a report from AVAC observed last year, if ending AIDS were a
business, the CEO would recognize that this is the time to invest. Donor nations must reinvigorate their commitments
to the Global Fund, as well as their own bilateral programs. Heavily affected countries should follow the
lead of South Africa and dedicate more of their own resources to the health of
their own people.

The U.S. needs to keep to the Administration’s three-year pledge to the
Global Fund, but not by undermining the overall response to AIDS by simply
shifting PEPFAR resources to the Fund.
That approach would be foolhardy, undercutting the President’s new PEPFAR
commitments and divesting from an enormously successful program with bipartisan
support that has brought international good will to the U.S. In fiscal year 2012, spending on global
health amounts to just one-quarter of one percent of the U.S. federal
budget. We can afford to begin to end AIDS, and, conversely, we won’t solve
our debt problem by slashing global health.

A third priority is achieving
global targets while addressing the needs of the most vulnerable populations,
including MSM, IDUs, and sex workers.
These groups are often invisible, their needs disregarded, and their
rights and safety openly abused. Doing
better to tackle AIDS among them requires promoting their human rights and
providing safe, tailored health services.
This will require resource allocation that reflects the epidemic profile
of a country, and adequate investment in the needs of most-at-risk populations
even where epidemiological studies have ignored their existence.

Ambitious global targets can drive accelerated service delivery and
development of more efficient systems.
Is there a contradiction between such targets and attention to those at greatest
risk, who may be harder to find and serve?
Not if the goal is truly and AIDS-free generation. As a World Bank/Johns Hopkins report released
last year demonstrated, in many places bringing overall HIV incidence down
depends on doing better at addressing the needs of heavily affected populations
such as MSM. It’s also true that because
MSM, IDUs, and sex workers are only now beginning to receive the attention they
need, a slowdown in the response to global AIDS would harm them most.

Finally, as always, research is
essential to success. It’s possible
to begin to end the AIDS epidemic now, but it won’t truly be over without a
cure and a vaccine. Research is also crucial to better understand how to
implement interventions in combination, to improve HIV diagnostic and treatment
options, and to successfully link newly diagnosed individuals to care and
treatment.

We have entered a time of huge promise in the AIDS epidemic, but with
it exists the very real threat that we will squander this opportunity by
under-investing or failing to use money wisely.
Now is the time for governments rich and poor, donors, providers,
researchers, and advocates to find new resources -- and make smarter use of
them -- to begin to end the most deadly epidemic of our time.

Chris Collins is vice president
and director of public policy at amfAR, The Foundation for AIDS Research. His e-mail is chris.collins@amfar.org.